Can the world's first full face transplant patient live with his new identity?

Propped up on crisp white pillows in a sunny ward, the patient's first words for five years will be mumbled through a stranger's lips.

As close members of his family lean over his bed to hear him, they may strain to understand what he is trying to say. They certainly will not recognise the face that the sounds are coming from.

The man in the hospital ward in Barcelona, Spain, will look younger than the loved one they remember before every feature on his 30-year-old face was blasted away in a freak and near-fatal shotgun accident in 2005.

World first: A computer-generated image released by the Vall d'Hebron hospital in Barcelona showing the area of the face that was transplanted

Yet the moment this brave patient begins to speak on Friday morning will be a triumph for modern medicine. For he is recovering from the world's first full face transplant.

The skin covering his face, the muscles and bones underneath, his nose, lips, chin, palate, eyebrows and eyelids belonged to another person who was several years his junior.

Today, this patient can only claim ownership of his eyeballs and tongue. They are all that remain of the original face of the patient nicknamed by the local Catalan nurses 'L'home Desconegut' or the 'Mystery Man'.

He underwent the pioneering operation, conducted over 22 hours by a team of 24 surgeons and junior doctors, just under a month ago.

Before that date, all you could see between his hairline and the top of his neck was a shiny patchwork of taut, grafted skin melding with a livid red mass of scar tissue.

He had a gaping hole for a mouth and no lips. He struggled to breathe through a nose that was unrecognisable as such. His eyes wouldn't close and his meals were mashed up so they could be spoon-fed to him by a team of round-the-clock helpers.

Lead surgeon: Dr Joan Pere Barret with an MRI image showing the ravaged face of a man who accidentally blew his jaw, mouth and nose away with a shotgun

After nine traumatic operations to try to patch up the damage of the accident, he lived as a virtual recluse - hidden away from the cruel remarks and disbelieving stares of the world outside.

Today, he is starting life anew. The doctor in charge of the groundbreaking transplant says that he is delighted by the youthful good looks of the man in the hospital bed. Dr Joan Pere Barret is obviously excited.

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'His new face is beautiful,' he tells me. 'You could say he is getting handsome. He looks less than his chronological age because the donor was a little younger.

'We are amazed at the result. His face is so natural. The muscles are firm. You can see just one scar across his neck, which looks like a wrinkle.'

'He is handsome. The results are really amazing'

He says that whole face transplants are the way forward. 'This is only the first of many, I am confident about that. For the best results, I would recommend any surgeon in the world to follow our example. The scarring is less visible. The results are so natural.'

Dr Barret says that the man will be out of hospital by the end of June. By Christmas this year, he will be fit enough to return to work and earn his own living again. Yet as the enormous impact of this breakthrough became clear yesterday, questions were being raised about the ethics of such a transplant.

The operation on the 'Mystery Man', whose identity is being kept secret by doctors under the strict orders of the Catalan Government, was paid for out of public funds.

This has raised concerns among politicians in Spain over the wisdom of spending thousands upon thousands of pounds on operating on a patient whose life is not at risk.

Breakthrough: These computer-generated images show the sequence of the procedure by surgeons for the world's first full face transplant

At the heart of the debate, too, is whether the human face is so sacrosanct that it should never be superimposed on anyone else's body.

No one knows how the patient will cope with his new identity. His face bears no resemblance to the donor because the underlying bone structure created by the doctors is different. But neither does his face look anything like his old one.

The man with the new face has undergone intensive psychological assessment by the Barcelona hospital's medical team.

It began four years ago to assess if he was a suitable candidate. The hospital started searching for a donor for him last August. Since then, the psychological counselling has been stepped up to ensure that he is ready for the trauma of a major operation and the consequences of having a different face.

Now, the psychologists are monitoring any mood swings as he comes to terms with his return home and mixing in normal society once again.

His family are also being counselled about the dramatic change in their circumstances, after five years of having a reclusive invalid at the centre of their lives. When he returns to his home town, he is unlikely to be recognised by people he has known since childhood.

He may feel shunned in the street simply because they won't know who he is. There is always a chance that even those who love him most will be uncomfortable with his new identity.

Because facial expressions are controlled by the brain, the Spanish surgeons say he is likely to smile, frown and even laugh in the same way as he did before the accident - although from of an entirely different face. He and his family will have to come to terms with all this, says Rafael Matesanz, the head of Spain's organ transplantation organisation.

'He will not have a completely perfect face. It is all about having a socially acceptable face,' he says.

But there are other obstacles ahead. The patient will be on powerful drugs until his dying day, to stop his immune system rejecting the face. The medicines can cause cancer and diabetes. He will have to visit hospital regularly for check-ups. 'His life will be very different from his old one before the accident,' Dr Barret said yesterday.

So how did the medical miracle happened? The 'Mystery Man' approached Dr Barret at Barcelona's Vall d'Hebron Hospital soon after a documentary about face transplants was aired on Spanish television in 2006.

The film featured Isabelle Dinoire, the French woman who a year earlier had received the world's first partial face transplant - including a new nose and mouth - after being attacked by her dog.

He is unlikely to be recognised in his home town

Nine partial face transplants followed in four countries: France, Spain, the United States and China.

In Britain, a team led by surgeon Peter Butler at the Royal Free Hospital in Hampstead, London, has received permission to go ahead with four full face transplants.

The first is expected to take place in the next year. 'Although he was very depressed at the time, we felt he was a good candidate right from the start,' explained Dr Barret.

'He was very calm. He had relatives who supported him. We felt we could change his life for the better and he remained top of our list.' What occurred next is unclear. It is known that in late March, a man in his 20s or early 30s was critically injured in a car accident in Spain.

A national alert had already been sounded in hospitals and among the emergency rescue services to help find a suitable donor for the Mystery Man. Crucially, the donor had to have the same blood group, skin colouring, size of face and distance between the eyes.

World's first partial face transplant recipient: Isabelle Dinoire in 2006, a year after her operation

There did not have to be a match of ethnicity but, as Dr Barret says: 'We wanted the donor in the same decade of life, more or less, as our patient. This is important because as we age our flesh droops and our muscles become less firm. We could not use the face of a much older donor on a younger person.'

But it can happen the other way round. The donor is now known to be slightly younger than the Mystery Man. After the car accident, he was taken to hospital, judged to be brain dead, and put on a life-support machine. The team waiting at Vall d'Hebron Hospital was informed.

The family of the man, who had a donor card giving permission for his liver and kidneys to be given to another person if he died, were then asked the difficult question: Would they agree to their loved one's face being transplanted on to another human being?

'In this case we asked them personally because it involved the face,' Dr Barret said yesterday. 'They agreed, but we had to meet them to sign documents and make legal statements.'

A little over 24 hours after the accident, the Mystery Man with his terribly damaged face was wheeled into an operating theatre at Vall d'Hebron to be prepared for the historic operation.

A few hours before that, in another operating theatre, doctors had begun another pioneering procedure to remove the face of the donor. Before the first scalpel pierced his skin, a mask of his face was made.

At the end of the operation, it was placed over the dead man's facial cavity to 'give dignity to the donor' and allow his relatives to grieve for him at an open coffin if they so wished.

He looked in the mirror and was happy with his face

Dr Barret refuses to say if the procedure to remove the donor's face took place at Vall d'Hebron or another hospital near to where the car accident occurred.

He says his silence is to preserve the anonymity of the donor because of an agreement with his family. Dr Barret says: 'I had good surgeon friends in another operating room harvesting the face.

'It took five hours to complete that process. The tissue was then brought in to the second operating theatre for the transplant to begin.'

The surgeons, under the direction of Dr Barret, worked through a night and a day in shifts of three hours to complete the transplant.

Then the Mystery Man was wheeled back to the plastic surgery and burns unit at the rear of the hospital. In a ground-floor room, overlooking the gardens, he began his recovery. A week after the operation, he signalled that he wanted to look at his new face in the mirror.

After viewing his reflection for the first time, he took a pencil and wrote down that he was happy with what he saw.

No regrets: Susan Whitman with her late husband Joseph Helfgot, who became a face transplant donor

'He is a very strong character and he gave the impression that he was at peace,' added Dr Barret, with satisfaction. So what do the years ahead hold for the Mystery Man - and the family of the donor who made it all possible?

To try and find out, the Mail this weekend talked to Susan Whitman, a widow whose husband became the donor in America's second partial face transplant almost exactly a year ago.

Tragically, Joseph, 60, never regained consciousness after a heart transplant operation. While he was on a life-support machine, doctors approached Mrs Whitman and the couple's four children asking-them for permission to donate Joseph's face.

Doctors transplanted Joseph's nose, the roof of his mouth, upper lip, facial skin, muscles and nerves to James Maki, whose own face was badly disfigured in 2005 when he fell on to an electrified railway line in Boston, Massachusetts.

New life: James Maki, the recipient of the second face transplant in the U.S.

Speaking from her home near Boston, Mrs Whitman said she has never regretted the heart-rending decision - although it was a deeply traumatic event for the family.

'The face is what identifies us as human beings. It's how we communicate. To take a face and put it on someone else is really hard for any family to get used to,' she says.

'It's difficult to understand that it's just another organ and no different to a heart or a kidney.

People need to know that in a facial transplant, the skin that you see is just a fraction of what is going on. What the surgeons are really doing is using someone else's tendons, blood vessels, nerves, muscles and even bone to build the new face.

'All of that tissue has to be realigned on the patient who has their own facial structure. The surgeons are putting it on a human template.'

Mrs Whitman says she has met James Maki, the beneficiary of her husband's face transplant. He lives near her. 'I see Jim Maki quite often,' she says calmly. 'There's a bit of trepidation before you meet someone who has your husband's face for the first time.

'But once we met, it took me about ten seconds to get over it. I don't think of Joseph when I see James. It's virtually impossible to tell that a person has received someone else's face. Joseph and James don't look anything like each other.

'Yes, it is my husband's nose. He had a very nice nose. But could I pick it out of 100 noses? No, I couldn't.

'Jim looks like Jim and that's it. People were shocked when Dr Joseph Murray carried out the first kidney transplant here in Boston in 1954, but now people don't think anything of it.'

Then she adds with a rueful smile: 'Maybe in another 50 years, people will get used to face transplants too. I hope so.'

They are words that will no doubt comfort the Spanish family who have both lost a loved one and made the courageous decision to give his face to a stranger.

In the ward of the Vall d'Hebron Hospital, the recipient will this week have the tube - which has helped him breathe since the transplant - removed from this throat.

Although the words through the donor's lips may be tangled at first, doctors are confident that he will soon speak properly.

This will be beginning of his future with a new face.

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Can the world's first full face transplant patient live with his new identity?